Medical Gray Zones
Michael Jackson died of cardiac arrest on June 25, 2009. Recently, a hearing started regarding his former personal physician Conrad Murray. In this hearing the physician is accused of involuntary manslaughter, negligence, and administration of a dangerous and unnecessary cocktail of medications that accelerated the superstar’s death.
While I won’t argue for the physician’s innocence, I do think we should ask – how common is the tendency to prescribe patients what they want? Is this a singular incident, a case of a drug-pushing “bad apple,” or could there be more general forces at play?
What I hear from my physician friends is that they feel tremendous pressure to please their patients, and they know that if they don’t give them what they want, some other physician will (or at least this is how they justify their overprescription).
A common case of this sort is the case of the influenza virus. When patients contract the flu, they go to their doctors, feeling miserable and begging for help. Doctors know that they shouldn’t prescribe anything for their viral patients (and that the best thing to do is nothing), but they feel a pressure to give the patients something as they walk out the door. And so, they prescribe antibiotics, which don’t treat the flu but do build up drug-resistant bacteria that may cause trouble in the future.
Doctors in this situation face a conflict of interest, between what the patient wants from them, what is good for their own wallet (to keep the patient happy), and what is the right medical thing to do. Moreover, the situation is not perfectly clear because while it is unlikely that the patient has a bacterial infection (one where antibiotics could help) it is still possible – creating a gray zone of medical practice.
The thing about medical gray zones is that they become grayer, more blurred, when patients are more powerful or high-profile. The minute a doctor has a patient like Michael Jackson who is wealthy and used to getting his way, the pressure to succumb has to be much higher.
In thinking about Michael Jackson’s physician, consider this. It’s easy to find someone guilty and lay the blame solely on that individual, one man who shamefully deviated from the standard of care, but it’s much more challenging to put ourselves in his position and think about what we would have done if we were in his position. I suspect we too would have prescribed those meds.
P.S. I can’t believe that I am writing a blog about Michael Jackson
The Honest Truth About Dishonesty: How We Lie to Everyone - Especially Ourselves
You might find Ben Goldacre’s writings on the placebo effect, over-prescription and quackery interesting. http://www.badscience.net/category/placebo/
The NHS does a lot to stop over-prescription here in the UK but I can imagine that it’s a major problem in the US and contributes significantly to your vast medical costs as a percentage of GDP.
Dan, a small typo: ‘dome’–>’some’
The inherent conflict is between the practice of medicine and the business of medicine. Palative treatment (pleasing the patient demand) is not much different than other service based business conflicts. Appraisers are often pushed to find justifications for higher or lower than real market values. Economists make assumptions based upon a variety of facts and pressures. Lawyers represent clients all the time and take positions consistent with client position, and finding rational and legal reasons to do so. Why should we expect more or less from medical practitioners?
Great column. I had a similar conversation with my GP a couple of years ago. Big difference was that the issue was drug advertising. Patients who came into his office with symptoms described in an advertisement and wanting the Doc to prescribe the advertised solution. The requests were frequently followed with “It worked so well for Uncle John!”
The doctor was then in a quandry – the requested drug would not cause harm but would not cause good
Trying to discuss the issue with an ill person usually does not work.
Sometimes he would give in; sometimes he would suggest that the requested drug was a bit strong for the patient’s symptoms and why don’t we start with something at a lower dosage.
Bottom line – this is a suprisingly serious and expensive problem. Why is it not discussed more openly?
I approached this issue as someone who managed benefits, including prescription drugs for an employer. The issue you brought up is just the tip of the iceberg. The entire drug system is rife with problems.
Thanks for writing this and for leting me vent
Hello Dan,
It is all too easy to play the blame game. What we are not seeing is how many other patients that Doctor may have helped and i suspect that in this case he will be judged as guilty unless he can prove his innocence.
Colin
Bruce Schneier (who coined the term “security theater”) made a similar observation about airline safety in this interview (http://www.popularmechanics.com/technology/military/news/tsa-scans-security-theater-interview):
Q: What’s the motive behind introducing this new level of security [backscatter scanners]?
A: It’s politics. You have to be seen as doing something, even if nothing is the smart thing to do. You can’t be seen as doing nothing.
I hear ya. Right now a friend of mine is dealing with both of his parents dying at the same time…of different cancers. And the physicians in both cases are telling their patients the truth, and in both cases the patients are insisting on radiation and chemo even though all it’s going to do is drag out the pain and suffering. And trust me, I am an old lady…almost 80 (few cryin’ out loud) I’m not talking “Death Panels” here. I’m talking dealing with reality. On the other hand…wonder what I’ll say when it’s my turn to deal with that reality thingy.
We need only to look close to home at our relationships with friends and family to see the same sort of behavior every day.
Many people cannot bring themselves to say no to their children, siblings, parents, friends and relatives, and vice versa.
Over-prescribing may be a national problem; however, under-prescribing nearly killed my son. He had strep throat, and the doctors sent us home every time saying it was viral. Our fourth doctor’s visit was to the closest (different hospital) ER where he was diagnosed with strep throat, streptococcal pneumonia, kidney failure, and sepsis!
It would have been much worse if they had perscribed medicines or illnesses they honestly thought he did not have.
Ok, let me see if I’m understanding this line of reasoning.
A consumer, thinking he knows what’s best for himself, “encourages” a doctor to prescribe meds (or perform a procedure, etc.) that the doctor knows are somewhere between ineffective and ill-advised.
The doctor succumbs to pressure from the patient, reasoning that if the doctor doesn’t give the patient what he wants, he’ll go elsewhere.
Where does this end? At what point do you have a doctor rationalizing that a patient would just buy narcotics on the street illegally if they weren’t prescribed, so he prescribes narcotics to fuel a drug habit?
The simple fact is that there’s a reason we require doctors to be highly trained, and then we hold them to some sort of standard of care. They’re supposed to know better than to fall for this. Given some sort of regulation, a doctor who flirts with accepted medical standards does so (nominally) in order to retain business, but he does so at the risk of a malpractice suit. To the extent that we take the teeth out of those regulations and enforcement, we start to put the inmates in charge of the asylum.
You’re absolutely right to ask where does it end. Unfortunately, you seem to think doctors make no distinction between drugs that are mostly harmless, and those that could ruin your life.
Large amounts of training does not make you immune to temptation.
dlambert, while I agree that a doctor should know what is best for his/her patient, I believe such a perspective is not in alignment with their reality.
As consumers we seem to expect exceptions to be made for our own benefit regardless what the rulebook/manual/policy says. It happens every day in uncountable contexts. When we don’t get our way we can be vindictive little bastards. And the Internet makes it all too simple to ruin the reputation of an individual or business when we don’t get exactly what we want, when we want it. Worse, there’s no way to tell if an on- or offline rant/claim is the result of a provider/vendor’s incompetence/negligence/opinion/error or simply a consumer aggravated that the company/individual refused to bend the rules in their favor.
It’s easy for us to write about what the doctors should do from the comfort of our laptops. I would not want to be in their shoes.
josephmartins – I never meant to imply that the doctors’ decisions are easy! On the contrary, it’s because the decisions are hard that we need them to be highly trained. I completely agree that there’s a natural tendency to push that envelope, but between the doctor and the patient, one of them is expected to have the qualifications to make those decisions correctly, and the other isn’t.
My understanding is that there’s a lot of grey area that arises when a patient requests treatments that go against the recommendations of a doctor, and I’m not sure that the laws are clear about who bears what sort of responsibility for those decisions. This, obviously, contributes to the confusion when something goes wrong.
I can’t tell you where we draw the boundaries of acceptable behavior today; I’m just trying to point out that the doctor has specialized training and expertise that are *supposed* to result in better decisions, while the patient is armed mainly with wikipedia and TV ads.
I think you see something similar with the recent mortgage problems, banks giving customers what they ask for, despite their knowledge that the 30-year-old part-time barista is unlikely to be able to keep up with mortgage payments for a quarter of a million dollar house.
It’s not a huge problem to prescribe something like pain killers to a single person, though the systemic misuse of antibiotics by everyone from doctors to chicken farmers has the potential to cause massive problems. It’s kind of scary, actually. I’m a little disappointed that none of the recent “health care” reform has addressed this in any way.
The real estate problem was worse than that. It was banks and mortgage companies encouraging the barista to buy a big house even when the barista said “Isn’t that more than I can afford.” “Think of your future,” said the banks, “Your income is sure to increase and houses always increase in value!”
Atul Gawande covered related ground, about the difficulty of having conversations that neither side really wants to have, in a recent New Yorker article: http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande.
I’d link back to your recent post on the girl in the burn ward. What makes someone able to or willing to get off pain medication? For many enough of us, it’s the need to work for money, which sometimes, pain meds can interfere with. Apparently, nothing ever got bad enough for Michael to get off meds before it was too late.
Collectively, we will probably blame the doctor for Michael’s death, and if you define the problem tightly enough, it will possibly be a just outcome. Dunno. The bigger problem is that we don’t have effective, non-addictive treatments for Big-P-pain, or that we don’t know how to help people solve life-history problems like Michael lived with.
Oh quit that touchy-feely tree-hugging whining about self-healing, time and rest – and just give me the strongest stuff you’ve got. I want to be a workaholic super-hero in the morning again.
But seriously, when going to a doctor with my son first we need to explain that although we’re concerned about his health, we want no drugs just in case. If waiting for three days, monitoring the condition to make sure it doesn’t get worse is the reasonable than we’re ok with it. And that we accept there’s some risk it’ll get worse which could have been prevented by taking drugs immediately. At this point I see the doctor starts being reasonable. Then, very often she says: “no, in this case risk is too much, I’ll prescribe the drugs”. But then at least we know she means it.
I was surprised to see you writing about Michael Jackson’s death too :p
I was even more surprised to see you taking on the medical profession again, after seeing the response you got on the dentist piece you did.
I was also surprised that there wasn’t a swarm of doctors that descended on you this time. I’m guessing that’s because this didn’t appear on NPR. Maybe it helped that you mentioned how you doctor friends shared their ethical struggle with you.
Perhaps you could investigate whether formal ethics training has an impact on behavior. One would like to think so; on the other hand, I don’t see ethicality as something you can instill in a classroom setting. It just doesn’t seem to have the right air of moral authority.
Just because we can sympathize with the forces that made someone make a wrong decision, doesn’t mean that the person isn’t to blame/wrong.
We seem to have a mentality in the United State of over consumption. Its not just about “keeping up with the Jone’s” either. The attitude that if I don’t sell, buy, steal, or consume that someone else will. I feel that most of the core values expressed in the U.S. parallels to that of a ambitious salesmen. Within the confines of that frame work it would be irrational to be medically pragmatic and turn down a patients request for medication. But hey, its all about business. Right?
Dan Ariely,
I’m a Sports Dietitian and I’d say that you can include Dietitians in the same group of Physicians and Dentists in the matters concerning this subject. It’s not rare you hear from a client that he (or she) is expecting the Dietitian to administrate supplements (whey protein, vitamins, antioxidants…) because that’s the way they evaluate if a diet is working out.
A few weeks ago an athlete friend of mine was complaining because her Dietitian did not prescribe supplements (he just adapted her diet) while his boyfriend’s Dietitian pushed a few pills (in my professional point of view). Then she changed the professional and told me she was very satisfied then. Hearing so I asked her if she now has been taking supplements for what she said ‘yes’!
You cited the influenza virus case in medicine. I don’t see myself as negligent (of course!) but sometimes you unnecessarily prescribe supplements (drug-pushing??) because I feel myself obliged to do so even knowing the products are useless because they have a strong placebo effect and they change the way they’d see the effectiveness of the new diet.
For some (amateur) athletes a diet with supplements make them feel themselves more ‘pro’, a better athlete. So, as a professional your mission is to describe safe products and make minor changes when they have a good diet otherwise you’d look like that very competent professional you talked about weeks ago that go to your house change your locks and end up with no tips even doing the right thing.
p.s.: I’m not saying that is the right thing to do! =)
Solution: If the patient thinks they know better, let ‘em go. There’s always more patients, and professional ethics are more important than the money one patient can bring you. A patient pushing for unnecessary procedures and medicines, whether wealthy or not, can only bring you bad in the end.
Case in point: facing a murder trial was probably not what this doctor had in mind when he started medical school. Had he stuck to his guns, he might not have had Michael Jackson as a patient. He definitely would not have had a murder trial to face. I don’t know about you, but I see an upside that HEAVILY outweighs the downside.
But, as always seems the case with Dan’s ideas, he can always find where people routinely throw out the rational decision and barrel toward the irrational one!
I find it interesting that so many people believe themselves to be rational when clearly Dan’s research shows that a majority of people are often irrational in many different types of situations.
In our minds it is never us and always someone else. In reality, if we saw ourselves through the eyes of others (or by way of experimentation) we’d be shocked by our own irrationality.
While I believe laws have an effect on keeping crime down its not the end all solution. Buy the time cops and lawyers are involved there has been a failing in the system. Granted there will always be failings, like there will always be mistakes, but lets not rely on our legal system to be the only tool we apply to fix our problems.
I think a lot of people missed the critical “gray area” aspect of Dan’s post. I recently had a bad cold, and I’ve had enough over my life to be able to tell when it’s just a cold and when it is starting to become something else, like sinusitis or bronchitis, which are treatable with antibiotics. Indeed my doctor gave me an antibiotic and indeed within a couple of days (after 2 weeks of increasing cold symptoms) I was symptom free. Doctors who knee-jerk and refuse antibiotics to anyone who at first seems to “just have a cold” may be guilty of undertreatment. Giving antibiotics to people with minor viral infections is a very trivial error compared with the vast abuse of antibiotics by the livestock industry, and it’s absurd to give either sick patients or the doctors who want to help them a hard time over it. The placebo effect alone is strong enough that it should count as a legitimate treatment.
If the placebo effect is all the doctors are after, maybe they should prescribe a placebo. Over use of antibiotics leads to antibiotic resistant bacteria which is a real and dangerous problem.
Regarding the self diagnosis thing, I used to get sinus infections all the time before I had nasal surgery. I knew what the symptoms were of an oncoming sinus infection and could pretty accurately predict when I was going to get one. If the doctor didn’t believe me, I’d get sicker, he’d change his diagnosis and I’d find a new doctor who would listen. So I guess you could argue I was part of the problem for that tactic.
On the same note, friend recently started having symptoms of a UTI, which she had had many times previously. The 24 hr clinic she went to didn’t believe her self diagnosis. So they ordered a blood test. 3 days later, she was proven right. So she was ill for 3 days and money was wasted on a blood test.
How do people who can accurately self diagnose (a minority I’m sure, and I could only predict my own chronic afflictions not anything else) fit into this grey area issue?
Also, I’m of an opinion that people should be allowed to go to a pharmacy and get whatever drug they want, doctor’s note or no. Perhaps some requirement for brief education about the drug from the pharmacist (as many do now anyway). Abuse aside, which occurs anyway, what are the arguments against that?
I have heard the general claim about overuse of antibiotics leading to resistant bacteria (which is surely true in general terms) used over and over to justify not giving antibiotics to individuals who appear to have only a minor viral infection. Is there any actual evidence that overuse of antibiotics in that specific situation (“retail” use as opposed to agriculture use) if NOT combined with a failure of the patient to complete the course of the medicine (always a problem with antibiotics even when prescribed for a genuine bacterial infection) has ever caused any particular bacteria to become resistant?
It seems to me that if there was a bacteria present that was in a position to become resistant, that rather implies that the patient in fact DID have a bacterial infection in the first place (and thus a legitimate claim to the use of the antibiotic), not just a viral one. After all, if a bacterial agent isn’t present, there’s nothing to become resistant. If there’s one present to be potentially subject to the resistance effect, then the patient did have a bacterial infection. Can someone please tell me what’s wrong with that logic?
There is much evidence. For example: Hawkey PM (September 2008). “The growing burden of antimicrobial resistance”. J. Antimicrob. Chemother. 62 Suppl 1: i1–9.
One point that may seem obvious – we have lots of bacteria in our bodies, good and bad, and having bacteria does not mean that you have an infection.
Thanks for the citation – an excellent literature review of the major issues in antimicrobial resistance worldwide. However, the article (which I read in its entirety) provides no evidence that giving individual patients in an outpatient setting who present with primarily viral “cold” type symptoms an antibiotic has played any significant role in the problem. In fact, it reinforces over and over the point I made that overwhelmingly the problem is due to agricultural practices (and it also makes the strong point about another major problem being transmission/contamination in hospital settings).
As to good bacteria, in most cases we probably aren’t too worried if “good bacteria” develop a little resistance (although the article cited did have one example of good bacteria gone bad due to resistance). So let me modify my sentence in my first post from “if there was a bacteria present” to “if there was a harmful bacteria present”, and repeat the point.
I always seem to have the opposite problem when I go to a doctor, whether it’s for a problem I’m having or if I’m going with a parent or grandparent. I try my best to learn more about what’s causing the problem and find alternatives to pharmaceuticals, but invariably the doctor wants to prescribe medications when I feel they aren’t warranted; sort of a just-in-case, I-need-to-cover-my-backside approach. Infinitely frustrating.
Suspect hand sanitizers that kill “99% of bacteria” have a bit of a hand in the mix, too. What’s left after you repeatedly kill 99% is the stuff that ethanol can’t touch.
Agree about big-business Ag use being the driver behind much antibiotic resistance. Feedlot defenders may say they only medicate sick animals. Truth is, all animals are sick. Cattle are not able to digest corn; their digestion gets off kilter, the deadly E. coli 0157:H7 takes over, and we get sick. Grass fed cattle don’t carry that strain of e-coli. Michael Pollan has a lot to say about this.
Re: we’d be shocked by our own irrationality.
Heavens, no! I gave up on rationality 25 years ago when rationality abandoned me. Life has been much more fun since. (That said, I am apparently the only driver in America who understands that we can’t ALL be “better than the average driver,” which perhaps suggests my irrationality is not as deeply rooted as I like to present to the world.)
I’ve never heard a “feedlot defender” claim they only use antibiotics on sick animals – all that I’ve ever heard are quite open (as are the agricultural colleges) in advocating the practice of using what is called “subtherapeutic” dosages. Try googling the word “subtherapeutic” all by itself (you don’t even need to add “antibiotics”) and see how many of the top 20 hits are specifically about antibiotic drugs used in agriculture.
There is a conflict in medicine. Medicine is a art based on science. Your doctor does know everything and either do you. An old stat professor once told me, what applies to a large population never applies to the individual. Same holds true in medicine. Sometimes I know better, other times the physician does. I expect my physician to stand up to me.
In most cases, I do think that mental disorders, such as ADHD and bipolar are over-diagnosed just because either patients or parents of the potential ADHD kids want to have an answer for these behaviors. Thank you sharing the story about MJ!!
I am a physician, so I see a lot of gray in all this.
I have two thoughts to contribute. The first is regarding antibiotic use. In their comments, people keep mentioning that some medical interventions are are not harmful and I totally disagree. Sometimes one has to stretch for a harm, but you don’t have to stretch about antibiotics; antibiotic resistance is real/dangerous on a population level and diarrhea is no fun for an individual. Diagnostic testing is not benign either if it exposes you to radiation, for instance. For that matter, diagnostic testing can cause a lot of anxiety which has a real human cost.
As for MJ’s doctor, the medications he was prescribing were way outside of his expertise. You don’t ask your Orthopedic doctor to prescribe your HIV meds and you don’t ask a Ophthalmologist to deliver a baby. However, I suspect that one does not become a Doctor To The Stars by being humble about your limits.
Also, I’m highly amused that the box in the reply form is “URI” and not “URL” (you want to know about my upper respiratory infection?)